Chapter 27 Anxiety, OCD, and Related Disorders

Anxiety

Emotional response to anticipation of danger

Stress (stressor)

External pressure on an individual

Fear

Intellectual appraisal of threatening stimulus

Historical aspects of anxiety

Once identified solely by physiological symptoms.

“Anxiety neurosis”

World War II and heart conditions

Focus of anxiety is now on:

Interrelatedness of mind and body

Epidemiology of anxiety disorders

Most common psychiatric illness

More common in women than men

Often coexists with other comorbidities (depression, phobias,…)

Studies support moderate genetic vulnerability

How much is too much?

Normality determined by individual societies.

Pathological anxiety

Pathological anxiety

Is out of proportion to the situation creating it

Interferes with social, occupational, or other important areas of functioning

Panic

Sudden, overwhelming feeling of terror or impending doom

Panic disorder

Recurrent, unexpected panic attacks

Persistent worry about panic attacks, and/or maladaptive behavior changes

Frequency and severity vary widely

What is needed to identify panic disorder?

At least four symptoms from DSM-5-TR needed

What is the average onset of a panic disorder?

Late 20s

What are risk factors for panic disorder?

Includes genetic vulnerability, history of trauma, and smoking

Generalized anxiety disorder (GAD)

Chronic, unrealistic, excessive anxiety and worry

Intense enough to cause significant impairment (avoidance and procrastination)

Depressive symptoms are common

Psychodynamic theory R/T GAD

Delayed ego development

Cognitive theory R/T GAD

Disturbed cognition results in disturbed feeling and behavior

Biological aspects of GAD

Genetics, neuroanatomical, biochemical, and neurochemical aspects.

Phobia

Irrational fear of a specific object, activity, or situation (often accompanied by intense anxiety or panic attacks)

Estimated to affect 8-12% of U.S. adults

Agoraphobia

Fear of being in places or situations from which escape or help might not be possible if panic symptoms occur

Fear of being outside of home alone

Impairment can be severe

Who is agoraphobia more common in?

More common in women than men

Social anxiety disorder (SAD)

Excessive fear the affected person might be embarrassed or be evaluated negatively by others

May be highly specific (eating/bathrooming in public) or general

Chronic, sometimes lifelong

Specific phobia

Excessive, unreasonable, and inappropriate fear of specific objects or situations

Diagnosis is only made is fear restricts individual

May experience little to no anxiety unless exposed to phobia

Psychoanalytic theory R/T phobia

Unconscious fears expressed in symbolic manner

Learning theory R/T Phobia

Conditioned responses learned by reinforcements

Direct learning or imitation (modeling)

Past experiences

Cognitive theory R/T Phobia

Negative self-statements and irrational beliefs

Loss of control

Biological aspects of phobia

Neuroanatomical and temperament

Medical conditions associated with anxiety symptoms:

Cardiac-heart attack and CHF

Endocrine-hypoglycemia, hypo/hyper thyroidism

Respiratory-asthma and COPD

Neurological-seizures

Anxiety can also be caused by substances because of ______ and _____

Intoxication and withdrawal

Obsessions

Intrusive, stressful, and recurrent thoughts, recognized as irrational but unable to be ignored

Compulsions

Repetitive ritualistic behaviors or mental acts, performed to reduce anxiety associated with obsessive thoughts

Intense anxiety r/t ______ and then use compulsions to _______

Obsessions; to soothe anxiety

Obsessive compulsive disorder (OCD)

Presence of obsessions, compulsions, or both

Causes distress or impairment in important areas of functioning

Individuals compelled to repeat the behavior for relief from discomfort

OCD is more common in:

Equally common among men and women

Body dysmorphic disorder

Exaggerated belief the body is deformed or defective in some specific way

Symptoms of depression and obsessive compulsive personality are common

In body dysmorphic disorder, if true defect is present:

Concern in unrealistic and grossly excessive

Trichotillomania

Recurrent pulling out of one’s hair

Preceded by increasing tension, results in sense of release or gratification

Comorbid psychiatric disorders common

Prevalence estimates vary widely

Hoarding disorder

Persistent difficulty discarding possessions regardless of their value (may be with excessive acquisition)

Symptoms become more severe with age

Treatment has met mixed results

Psychoanalytic theory

Underdeveloped egos for various reasons

Regression and defense mechanisms cause clinical symptoms of obsessions and compulsions

Learning theory

Conditioned response to traumatic event

Passive avoidance

Active avoidance

Psychosocial influences

Many trichotillomania cases relate to stress

Hoarding associated with unmanaged stress following loss or stressors

Assessment scales

Use subjective data

Appetite, pain, sleep, feeling, etc

Outcome criteria for panic and GAD

Patient recognizes signs of anxiety and intervenes before panic (panic and GAD)

Maintains anxiety at manageable level, makes independent life decisions (panic and GAD)

Outcome criteria for phobia

Patient functions adaptively in presence of phobic object/situation without panic

Verbalizes plan for responding in presence of phobic object/situation without panic

Outcome criteria for OCD

Maintains anxiety at manageable level without resorting to ritualistic behaviors

Patient demonstrates strategies for anxiety without resorting to ritualistic behaviors

Outcome criteria for body dysmorphic disorder

Verbalizes realistic perception of appearance and positive body image

Verbalize a realistic perception of his or her appearance and expresses feelings that reflect a positive body image

Outcome criteria for trichotillomania

Verbalizes/demonstrates adaptive strategies for coping with stressful situations

Verbalize and demonstrate more adaptive strategies for coping with stressful situations

Interventions for anxiety

Stay with pt, maintaining calm approach

Use simple words, calmly and clearly

If hyperventilation occurs, help pt breath into small paper bag over mouth and nose

Keep immediate surroundings low in stimuli

Administer meds as ordered by physician

When anxiety lessens, explore possible reasons for its occurrence with pt

Teach patient signs of escalating anxiety and ways to interrupt its progress

Fear interventions

Explore pt’s perception of threat and reassure them of their safety

Discursive reality of the situation and what aspects can be changed or cannot

Include pt in decisions of coping strategies

Referral to treatment for therapy may be needed

Encourage pt to explore underlying feelings that may contribute to irrational fears

Ineffective coping interventions

Work with pt to determine problematic situations

Initially meet dependency needs as required

Allow plenty of time for rituals and do not show disapproval of behavior

Support pt’s efforts to explore cause of rituals

Provide structured schedule of activity

Gradually limit time allotted for ritualistic behavior

Help pt learn to interrupt thoughts and behaviors

Disturbed body image interventions

Assess pt’s perception of body image

Help pt to see image is distorted or out of proportion to reality

Encourage verbalization of fears and anxieties

Involve pt in activities reinforcing positive sens of self unrelated to appearance

Refer pt to support groups

Ineffective impulse control

Support pt in efforts and explain it is possible to discontinue this behavior

Ensure nonjudgmental attitude is conveyed

Assist pt with habit reversal training (HRT)

Reinforce occupying hands when trigger is anticipated

Practice stress management techniques

Offer support and encouragement

Individual psychotherapy

Identify, explore, and resolve internal conflicts

Cognitive behavior therapy

Cognitive distortions (unrealistic/extreme)

Sound therapeutic relationship

Problem-solving approach

Behavior therapy

Systematic desensitization (reciprocal inhibition; placing in relaxed stat and then discussing)

Implosion therapy (flooding; build up rapor, then flood)

Complementary therapies/integrative health strategies

Used alone or integrated with medication